Tougher rules fail to prevent tragedies from plastic surgery

Young mothers, middle-aged men and grandparents. All were among at least 32 people who died in Florida in the past decade in the pursuit of beauty – soon after cosmetic surgery.

That's about the same number of deaths that occurred in the 1990s, leading the state Board of Medicine to pass rules restricting cosmetic procedures performed in doctors' offices – rules still considered among the toughest in the nation.

One reason for the continued deaths may be a huge growth in cosmetic surgeries, but some surgeons, malpractice attorneys and industry experts say problems persist, and the state needs to do more.

"If there are that many deaths, there's still something very wrong," said Becky Cherney, an Orlando health care advocate who was a member of the medical board that passed the rules. "People elect to have plastic surgery and they end up dying? It's a senseless loss of life."

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The deceased include four South Florida mothers in their 30s who went under the knife in the past two years to have love handles and bra rolls shrunk via liposuction, state incident reports and police records show.

In one case, a 32-year-old Miami mother of six went for liposuction at a Broward County plastic surgery office in February 2010. She died the next afternoon from a toxic mix of the surgical anesthetic lidocaine and oxycodone pain pills "complicating elective cosmetic surgery,'' according to an autopsy report.

Dr. Brett Coldiron, a University of Cincinnati dermatology surgeon who has researched plastic surgery in Florida, tallied 26 deaths and 131 hospitalizations from 2000 through 2009. The Sun Sentinel documented six deaths since then, through autopsy and police reports.

The deaths have had various causes, including poor medical care by doctors, bad reactions to anesthesia, and heart and breathing emergencies during surgery. Some were due to unavoidable complications that can happen in any type of surgery, even under the best conditions. The causes of the two most recent deaths have not been determined.

Florida's medical board tracks cosmetic surgery deaths and complications, but so far has not identified any trends or patterns that would require a change in the rules, said two board members from Fort Lauderdale, Dr. Zachariah P. Zachariah and Dr. Nabil El Sanadi. The medical board enforces laws involving physicians.

Both said the board should take another look at the issue, based on a cluster of five deaths in the past 21 months in Broward County.

"It's easy to second guess, but there needs to be a systematic approach to looking at all this," El Sanadi said. "Is it one place not complying with laws, or is it the system letting us down?... We don't know.''

The medical board first addressed the dangers of plastic surgery in 1999, after a series by the Sun Sentinel that found 34 deaths in the preceding 12 years. Some were blamed on lengthy surgeries involving multiple procedures at doctors' offices that were not then being regulated.

The board wrangled for two years before imposing rules that included regular inspections of physician surgery offices, a ban on overnight stays, and limits on liposuction and lengthy operations.

Since then, demand for elective cosmetic surgery has mushroomed nationally, fueled in part by public interest in celebrity surgeries and makeover shows on TV. The number of procedures nearly doubled since 2000 to an estimated 13.1 million last year, according to surveys of doctors done by the American Society of Plastic Surgeons.

Appearance-conscious Florida has been in the forefront. The number of doctors' offices registered to perform surgery jumped from 285 in 2004 to more than 400 today, state figures show. Half of those are in South Florida, with about 50 each in Broward and Palm Beach counties, and 100 in Miami-Dade. Some doctors appeal to modest-income families by offering discounted prices and payment plans.

Nationally, studies show a death rate of 2 per 100,000 cosmetic surgeries in physician offices. But no one counts the number of plastic surgery procedures in Florida so a statewide death rate cannot be calculated.

Coldiron said the industry has gotten better, but "cosmetic surgery is still not as safe as it should be in Florida."

Several malpractice attorneys said the state has not done enough to enforce the present rules and does not punish violators severely.

"The governor and Legislature talk a lot about protecting the medical industry," said Michael Freedland, a Weston attorney who represents families in two liposuction death cases. "I'd like to hear more talk about how we protect patients."

The president of the Florida Society of Plastic Surgeons, Dr. Randy Miller, said cosmetic surgery is safer under state rules and the vast majority of cases are complication-free. But he, Coldiron and other industry experts said the state needs to address some issues, including:

Unregulated surgery offices: Doctors are allowed to perform minor plastic surgery procedures in their offices, without their offices being inspected or regulated, as long as they use only local anesthesia. One 2009 death came after liposuction in an unregulated Weston office, called a medspa, that focused on beauty treatments.

Miller, of the plastic surgeons' group, said some patients have had complications when doctors at unregulated offices tried to do too much liposuction or surgery and gave patients overdoses of local anesthesia. "Absolutely without question, some of them push the limit," he said.

After the death at the Weston medspa in 2009, state Sen. Eleanor Sobel, D-Hollywood, filed legislation that would have required medspas to be regulated like other health facilities. The bills did not pass because legislative leaders had other priorities, Sobel said.

"We need to close the loophole," Sobel said.

Fort Lauderdale surgeon Dr. Robert Cline, a former medical board member, proposed during his term that the state consider banning or limiting liposuction in unregulated offices.

"Maybe 99 percent of the time there's no problem, but if you're [young and healthy] and something happens, that's a problem," Cline said.

The board addressed one concern last year. Officials barred doctors from doing complex and risky surgery in unregulated offices while using only pills as sedatives, said Christopher Nuland, attorney for the state plastic surgeons association.

Liposuction: The popular procedure to insert thin tubes under the skin to suck out fat was involved in 14 of 32 deaths counted by Coldiron and the Sun Sentinel and one-third of the Florida hospitalizations the surgeon studied. No other procedure had more.

Most of the problems involved extensive liposuction of patients under general anesthesia, Coldiron said. He suggested the state look for ways to encourage liposuction with local anesthesia in safe settings.

Medical malpractice attorney Lisa Levine, who has sued plastic surgeons over deaths and complications, said the state should consider banning liposuction in unregulated offices, a controversial suggestion that failed a decade ago

"They're not calling it invasive, but these are invasive procedures," Levine said.

Anesthesia: Coldiron said that more than two-thirds of the deaths and complications in plastic surgery involved general anesthesia, which renders patients unconscious.

In some cases, surgeons handling anesthesia without an assistant have mixed wrong concentrations of sedatives, Coldiron said.

Miller, of the surgeons association, suggested the state consider setting a maximum amount of anesthesia that can be used to avoid overdoses.

For example, when using the local anesthetic lidocaine, doctors may not realize they have made a mistake because it does not peak in the blood for 10 to 12 hours. A patient can seem fine in the doctor's office but then go into respiratory or cardiac arrest at home when the drug kicks in fully, Miller said.

Cherney said the state may want to revisit the idea of requiring anesthesiologists for more office surgeries, rather than allowing the surgeon or a nurse to administer the drugs. A decade ago, the medical board turned down the proposal because doctors objected.

Holding down costs: Some deaths and complications can be attributed to plastic surgeons trying to make procedures more affordable by reducing the cost of anesthesia or performing them in unregulated settings, which are less expensive, Miller said.

"What it really comes down to is money. There's such an emphasis on getting down the cost, certain corners are being cut," Miller said. "When patients try to go for the deal, go for the much lower price, the thing that is sacrificed in almost all cases is safety. When it costs half of normal and sounds too good to be true, it probably is not the best deal."